16 April 2012

Mental Health Institutions Lose Their Effectiveness

Story first appeared in the Los Angeles Times.

The bellboy and amateur composer from Sebastopol had been in the throes of bipolar disorder when he was charged with threatening the lives of co-workers. His family encouraged him to plead not guilty by reason of insanity, thinking that in a mental hospital he would get the treatment he needed.

Instead he was repeatedly brutalized. His main tormentor, a patient in the room next door, assaulted him several times, wrapping him in a headlock and sexually abusing him. Soon after, the same man strangled a psychiatric worker on the hospital grounds. These ordeals offer a window on the failings of a six-year effort to improve conditions in California's public mental hospitals at a cost of hundreds of millions of dollars.

In 2006, the U.S. Department of Justice sued the state, alleging that it was violating patients' rights by heavily drugging and improperly restraining them and failing to provide appropriate treatment. The state settled, agreeing to an extensive court-supervised improvement plan at four hospitals with more than 4,000 patients.

But a Times investigation found that the plan has failed to achieve the Justice Department's main objective: to raise the level of care so patients could control their violent tendencies and would not be institutionalized any longer than necessary.

Under the plan, the use of restraints and certain medications declined. But by the end of last year, the rate of patient assaults on other patients and staff members had doubled at Metropolitan State Hospital in Norwalk and Atascadero State Hospital in San Luis Obispo County, according to an analysis of state data. The assault rate at Napa more than tripled over two years, dropping only after the killing of the psychiatric worker triggered a lockdown.

Only at Patton State Hospital in San Bernardino did assaults decrease — by 15%.

Patients, most of whom have committed crimes linked to their illnesses, are also being confined longer, records show. Those judged not guilty by reason of insanity, for instance, were held nine months longer on average in 2011 than in 2006.

Despite the rising violence and longer periods of confinement, the Justice Department expressed overall satisfaction with the pace of improvements in the hospitals, and in November it allowed its oversight of Patton and Atascadero to expire.

But in December, the department unexpectedly asked a federal court to extend oversight of both Metropolitan and Napa, asserting in court papers that their patients remained at serious risk of harm, even death.

In support of that request, a federal court monitor charged with evaluating the state's progress cited 12 cases at the two hospitals in which patients died or were seriously injured because of lapses in care. A ruling is expected in June.

Meanwhile, the state Department of Mental Health — under new leadership — has begun dismantling many of the changes instituted at the hospitals. Under pressure from higher-ups to place the fewest possible restrictions on patients, hospital staff members grew reluctant to take assertive action against violent or unruly ones, according to state records and interviews with hospital officials, employees, patients and their families.

Paperwork intended to document progress toward about 360 separate objectives left staff members with far less time for patients and less flexibility to craft suitable treatments.

They have succeeded in putting in all these measures and employing people to count their forms. But in terms of reduction in cost, reduction in time served in treatment and reduction in violence, it's a failure.

The architect of the reforms was a Virginia-based consultant who came to the United States in 1987 from New Zealand, where he had served as psychology director at an institution for the mentally retarded. He became a professor of psychiatry at Virginia Commonwealth University and developed specialties in "person-centered" care — designed to build on a patient's strengths — and "positive behavior support."

Unfortunately, he had scant experience treating psychiatric patients, let alone the sort of dangerous offenders who fill the state hospitals. He specialized in research on the developmentally disabled, particularly children, and published articles about Buddhist-inspired mindfulness and alternative treatments, such as using the herb kava as a calming agent.

Yet he had at least one qualification that appealed to California officials: He was well-acquainted with the Justice Department lawyers who were scrutinizing the state hospitals. They had hired him 21 times over the years, mostly to advise them on problems with care at centers for the developmentally disabled.

After federal officials launched an investigation of Metropolitan, California retained him in 2002 to craft reforms there. Soon, he was shaping treatment at Napa, Atascadero and Patton as well. But the Justice Department sued anyway and after the state entered into a consent judgment, it kept Singh on to steer the reform effort.

He resigned abruptly in January 2011 after Times reporters inquired about his performance.

In written responses to questions, he characterized his tenure as a success, saying his expertise helped the hospitals shift from simply treating symptoms to providing individualized, personalized care that affords wellness, dignity and independence to the individuals served.

He is credited him with instituting rigorous treatment planning and reducing the use of restraints, isolation rooms and high-risk medications. And the rise in violence at the hospitals was blamed on an influx of patients with sociopathic tendencies. The hospitals' policies and procedures had improved under court supervision but that insufficient attention was paid to "outcomes" — whether patient health was also improving.

Patient kills staffer

On a drizzly Saturday evening in October 2010, a small woman walked across the Napa State Hospital grounds returning from her dinner break.A burly patient emerged from the dusk and dragged her into an alcove. The patient robbed her of $2, a pack of nicotine gum and jewelry. Then he strangled her so she would not tell on him, according to prosecutors. The patient was a diagnosed sociopath who'd been committed to the hospital after he stabbed and seriously injured a stranger. His one-on-one therapy had been discontinued and he had been given a grounds pass to attend the mall classes instead.

Throughout the state hospital system, employees protested that the federal reforms were making the facilities more dangerous to staff and patients. In particular, employees took aim at the reform effort's core approach to treatment: an assortment of group classes on such topics as anger management and substance abuse recovery. Mental health experts say the widely used mall approach is effective in teaching patients skills they will need to cope in the outside world.But in California the classes were often dull, repetitious or useless, employees and patients said. They largely supplanted individual therapy, which clinicians said was essential for patients to understand their illnesses and demonstrate fitness for release.

Many patients were frustrated with the classes.

High-functioning patients were thrown in with those ranting about "God and aliens," making it impossible to stay focused.

Seen as dismissive

Many therapists and other professionals in the state hospitals were put off by the approach of the reform and what some considered a dismissive manner in which it was handled. A cookie-cutter system was implemented ahead of attending to the true safety needs of an institution treating very dangerous individuals.

Staff members and some patients said that the reforms focus on documentation — aimed at proving compliance with the consent judgment — came at the expense of patients' well-being.

Monthly treatment plans grew to exceed 30 pages per patient, much of it redundant and clinically useless, current and former staffers said. Highly paid psychotherapists and other staffers were diverted from treating patients to audit and polish patient records for review by a federal court monitor.

With about 300 new forms to fill out systemwide, staff members said they no longer had time to play cards and chat with patients, activities that helped build connections and head off violence.

Patients said they missed the attention. Psych techs don't have time to be psych techs. They're irritated by the time they have finished with the paperwork.

The goal seemed to be technical compliance above all else, staffers said. At Patton, the hospital administrator told hospital police investigators in late 2009 to focus on patient abuse complaints for the six months that were subject to review by the court monitor's team and shelve the older ones, according to a letter to the monitor from a former lead investigator.

Even participation in the treatment mall was not what it seemed, staffers said. When charts showed that almost all patients were falling short of the required 20 hours a week of classes, the state lowered the bar — twice — so patients were considered noncompliant only if they didn't make it to a single class in a month.

Participation soared — at least on paper.

A family bereft

A former kindergarten teacher arrived at Metropolitan State Hospital in September 2009. She was diagnosed with schizophrenia in 1985 at 28, but had emerged from many crises to water-ski and paint once more, said her twin sister. In November 2009, she repeatedly somersaulted off her bed at Metropolitan in response to voices, according to an incident report. A staff member was assigned to watch her at all times.

Two days later, she began to flip off the bed again and was given Benadryl, an over-the-counter antihistamine and sedative. Soon she flipped again. Approached by a staffer, she asked to stay on the floor and rest. It was hours before anyone realized her neck was broken and she was paralyzed. She died in May 2010 of related causes.

Her family trusted that she was going to a facility that could manage someone with this severe of an illness. They questioned whether or not she could have been more properly medicated to avoid such circumstances. Documents reviewed by The Times show that staff members did not add anything to her usual medication other than Benadryl. She was not placed in physical restraints.

In general, mental health administrators at the hospitals pressed staff members to limit use of emergency calming medication, multi-drug cocktails and other similar measures, interviews and documents show.

Although clinicians generally supported non-coercive measures, they said higher-ups without medical training second-guessed the use of restraints, seclusion and medication even when they were necessary.

The paperwork and number of hoops you have to jump through and the backlash after the fact makes it virtually impossible to use these measures.

Metropolitan's former executive director, whose background is in social work, told clinicians to release patients from restraints and remove them from one-to-one observation in most cases, said several current and former staffers. She then denying trying to influence treatments, but instead stated that she encouraged clinicians to exercise clinical judgment since the application of restraints as well as ordering of one-to-one observation is based on a clinical decision. She abruptly left her state job in December.

In a May 2010 letter to Metropolitan staff, then the state's deputy director of long-term care, noted approvingly that by the end of 2009, seclusion events were nearly eliminated there and restraint events were down by 94%.

A January 2011 internal report acknowledged that Metropolitan staffers had frequently been reluctant to use restrictive practices, even when necessary. The report suggested that clinicians had misinterpreted the directives of superiors.

Because of a perception by some that the use of restraints or seclusion was essentially prohibited, there were often episodes where staff hesitated and delayed.

Monitor's concerns

Over the last two years, the federal court monitor has increasingly raised concerns about conditions in the hospitals.

In court papers filed in December, a psychiatrist chosen by state and federal officials to track the reforms, pointed with urgency to deteriorating patient safety at Napa and Metropolitan. He cited unacceptably high rates of incidents of serious injury from self-harm and aggression towards others.

Among his 12 examples was a 26-year-old patient at Napa who tried to kill himself by jumping from the top of a locker. Although a nurse's note said the young man reported hearing voices telling him to jump, he was not examined by a psychiatrist, nor was his medication adjusted. The patient later dived off a balcony and died.

In the meantime, many of the changes that the original reform instituted are being undone.

After defending the treatment mall for years, the state is abandoning it, providing treatment in the units where patients live so they aren't wandering the campus.

Most treatment plans are being slimmed down from 30-plus pages to one. Clinicians assigned exclusively to paperwork are returning to patient care.

Minimum staffing requirements under the consent judgment are falling by the wayside. And amid a state financial crisis, hospitals are cutting hundreds of clinical positions.

The Justice Department's Perez declined to comment on the state's retreat from many of the court-supervised reforms. A department spokeswoman said that the hospitals must respect patients' constitutional rights and that it is up to state officials to determine how.